EMPLOYMENT APPLICATION
This form may not allow sufficient space for provision of the information requested, or
other information you feel would be relevant to the application. If this is the case, please
include additional sheets.
PERSONAL DETAILS:
Post applied for: Medical Secretary
Where did you see the post advertised?
Surname:
First Name(s):
Address:
Postcode:
Telephone No:
Daytime:
Evening:
E-mail address:
Are you legally eligible for employment in the UK?
applicable)
Yes / No (delete as
Do you require a work permit to work in the UK?
applicable)
Yes / No (delete as
Please note that prior to making an offer of employment, we are required by law to verify
documentary evidence (and maintain copies for our files) regarding a candidate’s eligibility
to work in the UK. This applies to all applicants regardless of nationality/origin.
Have you any criminal convictions which are not ‘spent’?
Yes / No (delete as applicable)
If yes please give dates and details.
This post is exempt from the provisions of the Rehabilitation of Offenders Act 1974, which means
that applicants are not entitled to withhold any information requested about previous convictions
even if, in other circumstances, they would be regarded as ‘spent’ under the Act.
CURRENT (OR MOST RECENT) EMPLOYMENT OR WORK EXPERIENCE
Title of Post
Number of Hours worked per week:
Name and Address of Employer
Nature of Business
Salary and Hourly Rate
(Full time equivalent)
Summary of Duties Responsibilities
Reason for Leaving:
Postcode
Date of Appointment
Period of Notice / Contract End Date
PREVIOUS EMPLOYMENT OR WORK EXPERIENCE
Title of Post
Number of Hours worked per week:
Name and Address of Employer
Nature of Business
Postcode
Date of Appointment
Contract End Date
Summary of Duties Responsibilities
Reason for Leaving:
OTHER PREVIOUS EMPLOYMENT (most recent first - you may include unpaid work)
Please give a brief explanation of any periods of unemployment
Employer’s Name and Address
Title of Post Held
Salary and
Scale (FTE)
Date
From
Date
To
Reason for leaving
EDUCATION AND QUALIFICATIONS (most recent first). Include details of any
qualifications for which you are currently studying/expect to attain.
Schools, Colleges Universities or
other Training organisations
From*
To*
* Inclusion of qualification dates is not compulsory
Programme of study/examinations
taken (with levels and grades)
PERSONAL INTERESTS/HOBBIES
APPLICANTS WHO ARE PATIENTS OF THE UNIVERSITY OF NOTTINGHAM HEALTH
SERVICE
The University of Nottingham Health Service considers that employing staff who are patients
of the practice has significant disadvantages both to the patient and to the practice. Please
note therefore that if your application is successful, you will be required to register elsewhere.
REFERENCES
Please give the name, address and telephone number of two people who would be willing to
give you a reference. If you are currently or have recently been in employment, one of
these should be your current or last employer. If not, a referee should be a person who can
make a statement with regard to your character, e.g. a school or college teacher. Referees
must not be members of your family or related to you in any way.
Name
Name
Job Title (if applicable)
Job Title (if applicable)
Address
Address
Postcode
Telephone
Postcode
Telephone
How does this person know you?
How does this person know you?
If required, may we take up reference before If required, may we take up reference
interview?
before interview?
Yes / No (delete as applicable)
Yes / No (delete as applicable)
INFORMATION IN SUPPORT OF THIS APPLICATION
Please use the space below explain why you would be a good applicant for the
post, including any experience you have gained, skills you have to offer (for
example, IT skills) and personal qualities. This may include work and
voluntary/domestic activities (e.g. school committees, charity work). Please
relate your comments to the job description and advertisement. This box can
be extended to fit or you may continue on additional sheets as required.
Please continue on an additional sheet if necessary
If you are selected for interview, are there any reasonable adjustments you would need
us to make to make it easier for you to attend?
Yes / No (delete as applicable)
If yes, please give details:
APPLICANT’S DECLARATION
I hereby give my consent, in connection with this application, for all previous employers,
educational institutions and references to be contacted to obtain and verify the accuracy of
information provided by me in support of this application.
I understand that any misrepresentation or material omission made by me on this application
will be sufficient cause for cancellation of the application or immediate termination of
employment, whenever it may be discovered.
I understand that The University of Nottingham Health Service is permitted to hold personal
information about me as identified on this application form as part of its recruitment
procedures and personnel records.
Note: The University of Nottingham Health Service is an equal opportunities employer and
does not unlawfully discriminate in employment. No information provided by the applicant
will be used for the purpose of limiting or excluding any applicant from consideration for
employment on a basis prohibited by law.
Applicant’s signature:
Date:
This form should be returned to: Hayley Casey, The University of Nottingham
Health Service, Cripps Health Centre, University Park, Nottingham, NG7 2QW
no later than 09:00 Friday 27th May 2016.
DIVERSITY MONITORING INFORMATION
Date of birth:
[optional – you do not need to complete this] This page will be removed from the application papers
prior to assessment and is used only to monitor recruitment processes
Please tick the box which best describes your cultural & ethic origin
□ White British
□ White Irish
□ White European
□ Black British
□ Black Caribbean
□ Black African
□ Other white origin
□ Other black origin
Please specify:
Please specify:
□
□
□
□
□
Indian
Pakistani
Bangladeshi
Chinese
Other Asian origin
Please specify:
FOR OFFICE USE ONLY
DATE APPLICATION RECEIVED:
INTERVIEW:
SHORTLIST
NOTES ON REFERENCES:
YES / NO
YES / NO